15 year old with anemia under evaluation

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Unit II admission on 02/03/2021 

DR. JAYANTH ( INTERN) 

DR. AMULYA ( INTERN) 

DR. SURYA PRADEEP ( INTERN) 

DR. ASHA KIRAN ( INTERN)

DR. YAMINI ( INTERN) 

DR. VAMSHI ( INTERN)

DR. ISMAIL  (INTERN)

DR. PRADEEP ( PG 1st YEAR)

DR. DIVYA( PG 2nd YEAR)

DR. SUFIYA ( PG 3rd YEAR) 

DR. SATISH ( PG 3rd YEAR)

Faculty : DR. VIJAYALAXMI 

Here is a case i have seen: 

A 14 year old boy studying 8th standard presented with chief complaints of pain abdomen since 1 month loss of appetite since 1 month, poor stream of urine since 10 days and fever since 6 days. 

Patient was apparently alright 1 month back then he had abdominal pain which was insidious in onset associated with 2 episodes of vomitings and loose stools for 2 days, subsided after taking medication abdominal pain is associated with loss of appetite 

From 10 days patient is having poor stream of urine associated with dribbling of urine after micturition not associated with any burning micturition and from 6 days patient is having low grade fever continuous relieves on taking medication from 2 days patient is having evening rise of temperature associated with chills and rigors relieves on taking medication, not associated with cough, headache, tinnitus, burning micturition, ear discharge, ear pain. 

No past history of type 1 DM, HTN, asthma, tuberculosis. 

Regular bowel movements, 

No known allergies 

On examination: 

There are signs of pallor.

No signs of icterus, cyanosis, clubbing, lymphadenopathy, pedal edema 

Vitals: 

Temperature: 98.2F 

PR: 92/min 

BP: 100/60 mmhg 

RR: 22/min 

SpO2: 98% on RA 

CVS- S1 S2 heard 

RS- bilateral air entry present 

P/A- soft nontender 

CNS- higher mental functions intact 

No focal deficits 

Provisional diagnosis: 

? Anemia under evaluation 

Investigations: 

Treatment: on day of admission (02/03/2021)

 Tab pan 40mg/ OD 

Tab. PCM 500mg/ TID 

Temp charting 4th hourly 

GRBS charting 8th hourly

TREATMENT on day 1 (03/03/2021)

S-

Increased fever spikes yesterday night. 

Loss of apetite. 

Dark coloured stools passed. 

Pain abdomen on/off.

O-.

Patient is c/c 

SBP-120mmhg

PR-120bpm

Pallor present. 

CVS-S1S2 heard, apical impulse 1cm medial to MCL  in 5th ICS. 

RS-BAE present. 

CNS- No FND

PA-Soft and non tender, liver and spleen not palpable. 

No palpable lymph nodes. 

A-

ANEMIA UNDER EVALUATION. 

P-

1.Tab PAN 40mg/ OD 

2.Tab. PCM 500mg/ TID 

3.T. ALBENDAZOLE 400mg PO STAT. 

4.Temp charting 4th hourly 

5. Teppid sponging SOS. 

6. Inj. ARTESUNATE 120mg  0,12,24hrs.

7. BP, PR, RR monitoring. 

8. Inj.  IRON SUCROSE 1amp in 100ml NS over 30mins.

Sr. LDH- 154

PS- Microcytic hyprochromic anemia

TREATMENT on day 2 (04/03/2021)

S-

Stomach pain decreased. 

Appetite improved. 

No urinary symptoms. 

No fever spikes. 

O-

Patient is c/c.

Temp-98F

BP-110/40mmhg

PR-118/min

CVS-s1s2 present

RS-BAE+

CNS-No FND

PA-Soft, NT

A-

IRON DEFICIENCY ANEMIA

P-

1.Tab PAN 40mg/ OD 

2.Tab. PCM 500mg/ TID 

3.Temp charting 2nd hourly 

4. Teppid sponging SOS. 

5. Inj. ARTESUNATE 120mg 0,12,24hrs.

6. BP, PR, RR monitoring. 

7. Inj.  IRON SUCROSE 1amp in 100ml NS over 30mins.

TREATMENT on day 3 (05/03/2021)

S- 

No new complaints 

Fever spikes + 

O-

 pt is c/c 

Bp- 110/50mmhg 

PR- 118/min 

CVS- S1S2 heard 

RS- B/LAE+ 

CNS- no focal deficits 

P/A- soft non tender 

A-

 IRON DEFICIENCY ANEMIA

P-

Rx; 

1.Tab. Pan 40mg/PO/OD

2.Tab. PCM 500mg/ PO/ TID 

3.Inj. IRON SUCROSE 1 amp in 100 ml NS over 30min / BD 

4.Temp charting 2nd hourly 

5.BP, PR, SpO2, RR monitoring 

6.Tepid sponging 

7.Thrombophobe ointment for L/A

8. T. NORFLOXACIN BD started night after getting c/s reports. 

TREATMENT on day 4 (06/03/2021)

S- 

No new complaints 

Fever spikes + 

O-

 pt is c/c. 

Bp- 110/50mmhg 

PR- 106/min 

CVS- S1S2 heard 

RS- B/LAE+ 

CNS- no focal deficits 

P/A- soft non tender 

A-

 IRON DEFICIENCY ANEMIA

P-

Rx; 

1.Tab. Pan 40mg/PO/OD

2.Tab. PCM 500mg/ PO/ TID 

3.Inj. IRON SUCROSE 1 amp in 100 ml NS over 30min / BD 

4.Temp charting 2nd hourly 

5.BP, PR, SpO2, RR monitoring 

6.Tepid sponging 

7.Thrombophobe ointment for L/A

8. T. NORFLOXACIN 400mg PO BD.